2013 naiis summit section 6: quality and measures
TRANSCRIPT
Copyright 2011 The Joint Commission 1
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2013 NAIIS Summit
Section 6: Quality and
Measures Workgroup:
Overview of Measures –
Measures 101
Sharon L. Sprenger
Co-Lead Quality and Measures Workgroup
Director, External Measurement Relations
Division Healthcare Quality Evaluation
The Joint Commission
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What are Measures?
Definition Measure
n. A standard: a basis for comparison; a
reference point against which other things
can be evaluated; “they set the measure for
all subsequent work.” v. To bring into
comparison against a standard.
Source: NQF ABC’s of Measurement
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Why are Measures Important?
Qualitative tool
Quality Improvement
Drive better health care
Consumers/Purchasers informed decisions
Accreditation/Certification
Public reporting
Payment (Private and Public)
– Pay for Reporting
– Pay for Performance
……..
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The Donabedian Model
Avedis Donabedian, known for his
contributions to the field of health care, first
described in 1966 three dimensions that can
be used to assess quality, which became
known as the Donabedian model
According to the model, information about
quality of care can be drawn from three
categories: “structure,” “process,” and
“outcomes”
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Structural Measures
Structural Measures
reflect the conditions in
which providers care for
patients. These
measures can provide
valuable information
about staffing and the
volume of procedures
performed by a provider
Source: National Quality Forum (NQF)
ABC’s of Measurement
Example: Adoption of
Medication e-Prescribing
– Documents whether
provider has adopted a
qualified e-prescribing
system and the extent of
use in the ambulatory
setting.
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Process Measures
Process Measures
show whether steps
proven to benefit
patients are followed
correctly. They
measure whether an
action was completed
— such as writing a
prescription,
administering a drug, or
having a conversation.
Source: NQF ABC’s of Measurement
Example: Childhood
Immunization Status
– Percentage of children 2
years of age who had
four DtaP/DT, three IPV,
one MMR, three H
influenza type B, three
hepatitis B, one chicken
pox vaccine (VZV), and
four pneumococcal
conjugate vaccines by
their second birthday.
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Outcome Measures
Outcomes Measures
take stock not of the
processes, but of the
actual results of care.
They are generally the
most relevant
measures for patients
and the measures that
providers most want to
change.
Source: NQF ABC’s of Measurement
Example: Surgical
Site Infections
– Percentage of
surgical site
infections occurring
within 30 days after
the operative
procedure.
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Patient Experience Measures
Patient Experience
Measures record
patients'
perspectives on
their care
Source: NQF ABC’s of Measurement
Example: CAHPS
Clinician/Group
Surveys — (Adult
Primary Care, Pediatric
Care, and Specialist
Care Surveys)
– Surveys of patient
experience with
primary care for
adults and children
and with specialist
care
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Composite Performance
Measures Composite
Performance Measure
is a combination of two
or more component
measures, each of
which individually
reflects quality of care,
into a single
performance measure
with a single score. Source: National Quality Forum.
NQF Composite Performance
Measure Evaluation Guidance
2013
Example: Mortality
for Selected
Conditions
– Measure of in-
hospital mortality
indicators for
selected conditions
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Additional Examples Composite
Measures
STS CABG Composite Score, NQF#0696
consists of four domains and 11 individual
measures
AHRQ Patient Safety for Selected Indicators
Composite (PSI #90), NQF#0531 consists of
8 individual measures
Source: http://www.qualityforum.org/QPS/
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Measure Calculations
Rate-based – Proportion: numerator is a subset of the
denominator population
– Pneumococcal Immunization (PPV 23)
– Ratio: numerator is not a subset of denominator, but a relationship exists between them
– Central line-associated bloodstream infections per central line device days
Continuous Variable Measure (aka central tendancy): a simple mathematical average
– Median Time from ED Arrival to ED Departure for Admitted ED Patients
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What Does Measure
Harmonization Mean?
The standardization of specifications for related
measures with the same measure focus (e.g.,
influenza immunization of patient in hospitals or
nursing homes), or related measures for the same
target population (e.g., eye exam and HbA1c for
patients with diabetes), or definitions applicable to
many measures (e.g., age designation for children)
so that they are uniform or compatible, unless
differences are justified (e.g., dictated by the
evidence).
Source: NQF
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What Does Measure
Harmonization Mean?
The dimensions of harmonization can
include numerator, denominator, exclusions,
calculation, and data source and collection
instructions.
The extent of harmonization depends on the
relationship of the measures, the evidence
for the specific measure focus, and
differences in data sources.
Source: NQF
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How are Measures Developed?
Identify focus/measure concept(s)
Literature review/evidence review
Expert input, e.g., Expert Advisory Panel
Measure identification
Measure specifications
Public comment
Testing
Implementation
NQF endorsement
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How are Measures Endorsed?
National Quality Forum (NQF)
The NQF is a nonprofit organization that
operates under a three-part mission to improve
the quality of American healthcare by:
– Building consensus on national priorities and
goals for performance improvement and
working in partnership to achieve them;
– Endorsing national consensus standards
for measuring and publicly reporting on
performance; and
– Promoting the attainment of national goals
through education and outreach programs.
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NQF - Voluntary Consensus
Standards-Setting Organization
NQF uses a formal Consensus Development
Process, and is recognized as a voluntary
consensus standards-setting organization as
defined by the National Technology Transfer
and Advancement Act of 1995 and Office of
Management and Budget Circular A-119.
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NQF Endorsement
Measure Evaluation Criteria
1. Evidence, Performance Gap, and Priority
(Impact)—Importance to Measure and
Report
2. Reliability and Validity—Scientific
Acceptability of Measure Properties
3. Feasibility
4. Usability and Use
5. Comparison to Related or Competing
Measures to address harmonization and/or
selection of the best measure
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The Changing National Measure
Landscape Ten Years Ago Today
Few measures
across relevant
areas
Too many measures
or not the right
ones, yet measure
gaps
Industry resistance Willing participation
No uniform data
collection
Increasing
standardized data
collection and
reporting
Little improvement
driven by measures
More efforts
devoted to
improvement
No experience with
measure use
Increasing
experience with
measure use
PPACA ACA – Going Forward
National Strategy for Quality Improvement
in Health Care with national priorities,
catalyst and compass for nationwide focus
public and private sector. Aligned
measures across programs.
Interagency Working Group on Health
Care Quality; multi-stakeholder input
Secretary established and implemented
overall framework public reporting;
defined steps between measure
identification and public reporting
Use performance measures to track
quality, form the basis of payment
incentives or reductions, and help the
public make informed choices
AHRQ authority to identify, develop,
evaluate, and disseminate innovative
strategies for QI practices
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Changing Environment
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A whole new world – learning
eTalk
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Some of the EHR Challenges
to Measurement: People
Workflow issues
EHR use
– Copy and paste
– Location of information and
comprehensiveness
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Some of the EHR Challenges
to Measurement: Technical
Lack of EHR standardization
Constraints and artifacts of clinical
documentation
– A plethora of terminologies (SNOMED,
LOINC, RxNorm)
Immature Health Information Exchanges
(HIE) Networks
– Interoperability
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Some of the EHR Challenges
to Measurement: Technical
Clinical Decision Support (CDS) evolving
Immature frameworks and tools for
standardized eMeasure representation
and reporting
– HL7 standards for eMeasure
specifications (HQMF) and data
transmission (QRDA)
– Information model for electronic
representation of measures (QDM)
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